Immunotherapies have permanently changed the landscape of cancer therapy and there may be a continued expansion of the indications, complexity and targets leveraged to treat cancers, according to papers published Jan. 12 in JACC: CardioOncology.

In one paper, Lili Zhang, MD, ScM, FACC, et al., summarize the published data on the epidemiology, diagnosis and management of cardiotoxicity of immune checkpoint inhibitors (ICIs). They note that myocarditis should be a principle diagnosis under consideration in patients on ICIs with new cardiovascular presentations.

The authors explain that initial testing should include electrocardiogram, cardiac biomarkers, echocardiogram (with global longitudinal strain) and cardiac magnetic resonance imaging. They add that the first-line treatment of ICI-associated myocarditis, beyond holding the ICI, is immunosuppression with corticosteroids.

"As physicians who are fortunate to care for cancer patients, we must keep pace with this transformation," the authors write. "Our understanding of cardiotoxicity related to cancer immunotherapies must improve as these novel therapies are being increasingly applied to a broader range of cancers, to cancers in earlier stage, and to community settings."

In a separate Viewpoint, Franck Thuny, MD, PhD, et al., outline the French Working Group’s approach for ICI cardiovascular monitoring and explain how ICI-induced myocarditis is one of the most serious complications of cancer treatment. They point out the urgent need for management protocols – ones that should be updated as knowledge evolves and that are tailored to specific situations.

The authors also emphasize that increasing prescription of ICIs makes it imperative to provide new data to address the following issues related to ICI-induced myocarditis: 1) What are the clinical, biological and imaging predictors of this complication? 2) Are there predisposing genetic factors? 3) Is it possible to establish a preventive strategy? 4) What are the predictors of poor prognosis? 5) What is the best immunosuppressive therapeutic strategy? 6) Is it possible to rechallenge ICIs in some patients after an episode of myocarditis?

"Knowledge of the cardiovascular toxicity associated with cancer immune therapies is increasing, but many uncertainties remain," the authors conclude. "Cardiologists and oncologists urgently need practical management protocols, which will need to be updated regularly as research and our understanding evolves."

To reinforce learning on this topic, JACC: CardioOncology Editor-in-Chief Bonnie Ky, MD, MSCE, FACC, et al., recorded a discussion examining a patient case depicting early immune checkpoint inhibitor cardiotoxicity. Watch now.

Clinical Topics: Cardio-Oncology, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Magnetic Resonance Imaging

Keywords: Cardiotoxicity, Myocarditis, Immunotherapy, Biological Evolution, Neoplasms, Magnetic Resonance Imaging, Immunosuppression, Electrocardiography, Adrenal Cortex Hormones, Prescriptions, Prognosis

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